Medical Director — Utilization & Case Management Leader

Highmark; United States; On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to join a dedicated team performing utilization management in line with current clinical standards. You will review escalated cases against medical policy, engage in peer to peer discussions when required, and ensure regulatory compliance across multiple agencies.

You will participate as the physician member of the multidisciplinary CMDM team, advise on high‑risk cases, and support process improvements with targeted projects and protocol development.

Qualifications

• MD or DO medical degree required.
• Active medical licensure in applicable state(s).
• Board Certification by ABS or AOA recognized boards.
• Experience in clinical management or utilization review is preferred.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy criteria.
• Determine medical necessity and appropriateness, including peer discussions when needed.
• Ensure compliance with NCQA, URAC, CMS, DOH and DOL regulations.
• Participate on CMDM multidisciplinary team; advise on high‑risk cases.
• Contribute to protocol/guideline development and special projects.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA/MPH (preferred)

Job description

Highmark Inc. is seeking a physician to join a dedicated team performing utilization management in line with current clinical standards. You will review escalated cases against medical policy, engage in peer to peer discussions when required, and ensure regulatory compliance across multiple agencies.

You will participate as the physician member of the multidisciplinary CMDM team, advise on high‑risk cases, and support process improvements with targeted projects and protocol development.